Monday

As RHS walked past the employee bulletin board this morning, he noticed a letter posted by a couple who had been long-time patients of his. The letter complimented the nursing and clerical staff of the practice. RHS was gratified by this, and it reminded him of the importance of the support staff to the effectiveness of a family practice. He recalled how fortunate he had been, over his 50 years of practice, to have a long line of dedicated and caring staff members. He also reflected that a major portion of whatever success he had enjoyed within his practice could be largely attributed to the quality of his support staff. Care in selecting employees, providing appropriate support for employees, and maintaining a caring and respectful approach to patients and staff is key to cultivating a happy and successful family practice.

Tuesday

PRP, the physician assistant, gave birth to her third child today. The delivery was accomplished with little difficulty, which had been expected because of her two previous uneventful deliveries. Nevertheless, RHS was relieved. He recalled that multiparity and previous easy deliveries are no guarantee of a similar outcome. In fact, he remembered an instance where a patient, who was gravida 11 with no previous problems, suffered a massive abruptio placentae at home prior to the onset of labor. Another patient was gravida five, and RHS had tried to perform the delivery at home because she was snowbound. He discovered, however, that she had a transverse lie and a prolapsed arm. Both women had required an emergency cesarean section. RHS was thankful for PRP's successful delivery, and he reflected that, regardless of a woman's pregnancy history, delivery is a time to be alert.

Wednesday

Twenty-eight-year-old Heather presented to JDF complaining of a greater than one-year history of “sore hands.” She had been suffering early morning stiffness, chronic back pain, arthralgias, erythema, and swelling of the hands, wrists, elbows, and feet. Heather also had a history of recurrent oral ulcers for which she had been repeatedly evaluated in the past. A family history of systemic lupus erythematosus was noted. She had no history of tick bites, fever, chills, myalgias, rashes, or skin changes. Physical examination revealed mild synovitis of the proximal interphalangeal and metacarpophalangeal joints bilaterally, sausage-shaped digits, and several aphthous ulcers. The diagnosis was uncertain until Heather mentioned that she was unable to grow long fingernails. Upon examination, her nails were brittle, and oil spots and pitting were noted. There were no skin abnormalities. Subsequent laboratory tests led JDF to a diagnosis of psoriatic arthritis.

Heather's symptoms were markedly improved with pharmacotherapy. JDF now firmly believes in the caveat that her dermatology colleagues have always recommended: “Don't forget to look at the nails!”

Thursday

Mrs. Winters was an elderly woman with dementia who lived at the local retirement home. She wasn't very vocal, but was generally pleasant and cooperative. She arrived one morning with a complaint of “right leg pain.” Review of her chart revealed recent communication from the retirement home that she was complaining of right leg pain. An order was sent for low-dose narcotic-containing pain medication, as needed. No other history was provided, and that morning Mrs. Winters would not utter a word. CSJ performed the initial examination with Mrs. Winters in the wheelchair because she resisted attempts to assist her to an examination table. She was noted to have tenderness on palpation of her pelvis, but other findings were consistent with her advanced age. A call to the retirement home revealed that Mrs. Winters had in fact fallen several days prior to the request for pain medicine, but that she was still ambulatory. Since then, she had become irritable and had stopped ambulating. Finally, Mrs. Winters was lifted to the x-ray table, where a hip fracture was evident. She was transported to the hospital for surgery. Staff and clinicians alike were reminded how important good communication between caregiver and clinicians can be. The more specific caregivers can be when reporting problems with residents in their care, the better, and more expedient the care we can provide for them.

Friday

One of RHS's patients this afternoon was the daughter-in-law of one of the three grandmothers mentioned in “Diary from a Week in Practice” in the January 15, 2002 and May 15, 2002 issues of American Family Physician. After going home that evening, RHS was called and told that there had been a four-wheeler accident about eight miles south of town and that a fatality necessitated the presence of a Medical Examiner. On the way to the address, it occurred to him that this was in the vicinity of the grandmother's home. On arriving, he discovered that it was indeed her home, and that the deceased was her 13-year-old grandson and the son of the daughter-in-law RHS had seen earlier that day. After completing his duties as Medical Examiner, he had the task of ministering to a distraught mother and father whom he had known all of their lives. The sharing of tragedy and supporting of families at such times is an integral part of “continuing comprehensive care.”

Saturday/Sunday

This afternoon, RKT had to inform a patient that his renal cell carcinoma had metastasized to his liver. RKT had initially diagnosed the patient's renal cell carcinoma, and a lengthy discussion had ensued. The patient was convinced that if he underwent surgery to remove the affected kidney, the “air” introduced into his abdominal cavity from surgery would cause his cancer to spread. Only after repeated reassurance that this was the best course of action did this patient finally agree to undergo nephrectomy. Unfortunately, several lymph nodes removed in the surgery were positive. RKT explained to the patient that he did have positive lymph nodes and that metastasis was not unexpected. Despite his explanation, however, RKT realized that the patient will probably always feel that exposing his cancer to air was the cause of the metastasis. This is a difficult part of family practice that RKT and other physicians must struggle to accept.

Robert H. Shackelford, M.D., is one of five physicians at Mount Olive Family Practice in Mount Olive, North Carolina. Dr. Shackelford and his colleagues, which include three physicians assistants, provide all types of care (except obstetrics) to patients of all ages in their rural community.